Systemic thrombolysis and anticoagulation improved biomarker measurements in massive-like pulmonary embolism and severe COVID-19 pneumonia: a case report

Abstract

Background From asymptomatic patients to severe acute respiratory distress syndrome, COVID-19 has a wide range of clinical presentations, and venous thromboembolism has emerged as a critical and frequent complication. Case summary We present a case of a 69-year-old man with a clinical presentation of massive-like pulmonary embolism (PE) overlapping with severe COVID-19 pneumonia. The diagnosis was made based on hypotension, severe oxygen desaturation (33%), and right ventricular dysfunction (RVD). We used alteplase and low-molecular-weight heparin, obtaining immediate clinical improvement. Also, we identified an extremely elevated D-dimer (31.2 mcg/mL), and computed tomography pulmonary angiography (CTPA) revealed an unexpected low thrombus burden and a crazy-paving pattern. Considering this, we decided to discontinue the alteplase. Therefore, the mechanisms of pulmonary hypertension and RVD could be multifactorial. Despite the patient’s respiratory status worsening and ongoing mechanical ventilation, biomarkers kept lowering to normal ranges. It appears a favourable outcome was related to early PE diagnosis and a multimodal therapeutic approach. Discussion Physicians in the ER should be warned about extremely high D-dimer measurements and severe oxygen desaturation as possible markers of severe COVID-19 pneumonia in patients with high-clinical suspicion of PE. Although ESC guidelines recommend immediate reperfusion in cardiogenic shock secondary to PE, we suggest initial CTPA in patients with high-clinical suspicion of severe COVID-19.

Risk Factors, Clinical Presentation, Therapeutic Trends, and Outcomes in Arterial Thrombosis Complicating Unvaccinated COVID-19 Patients: A Systematic Review

“…Emerging evidence suggests that COVID-19 is characterized by endothelitis secondary to direct viral infection facilitated by the overexpression of angiotensin-converting enzyme receptor 2, the receptor for cell entry of SARS-CoV-2 in endothelial cells, highly expressed in the lungs, heart, veins, and arteries. 18 , 27 , 28 SARS-CoV-2 in most patients causes a high prothrombotic state inducing thrombosis through inflammation pathways, endothelial activation, immunothrombosis, 29 cytokine storm, 30 and coagulation system activation. Dysregulation of the renin-angiotensin system and the innate and adaptive immune system also plays an essential role.…”

“…Dysregulation of the renin-angiotensin system and the innate and adaptive immune system also plays an essential role. 30,31 All these mechanisms associated with in-hospital and ICU risk factors 30 explain the high incidence of venous thromboembolism. [8][9][10]17,31 SARS-COV-2 inflammation can destabilize a vulnerable plaque 32 in the elderly with ischemic heart disease and subclinical atherosclerosis.…”

Impact of Alteplase on Mortality in Critically Ill Patients with COVID-19 and Pulmonary Embolism

“…The patients were diagnosed with COVID-19, ADRS, and PE, and thrombolytic therapy was successfully performed in all of them [ 52 ]. Betancourt-Del Campo et al [ 53 ] presented a case of a 69-year-old man with severe COVID-19, respiratory failure, and acute right ventricular insufficiency who was successfully treated with alteplase. Aguilar-Piedras et al [ 54 ] presented an interesting case of a 53-year-old multimorbid patient with COVID-19, who rapidly deteriorated due to pneumothorax and PE and was successfully treated with a half-dose of alteplase.…”